Tuberculosis: a war that must be won on the ground and in the field

José Luis Castro is President and Chief Executive Officer, Vital Strategies; Chair, The NCD Alliance; and Executive Director, The International Union Against Tuberculosis and Lung Disease (The Union).

Once, in a low-income country, I witnessed a dismaying scene: cartons of life-saving medicines stacked high in a storeroom, going nowhere as they slowly spoiled – because public health workers could not get them to the remote villages where people lay dying for want of them. This disturbing image comes to mind – as do similar tales of lives lost because of health-system inadequacies – whenever talk runs high of anticipated new scientific breakthroughs in my organisation’s primary disease of concern, tuberculosis. The status of detecting and treating tuberculosis today is one of paradox: the tools to eradicate it exist – but we aren’t deploying them effectively enough to save all the lives that could be saved.

Consider some of the evidence:

· Sophisticated new diagnostic tools have emerged recently – but they are of limited use in the some rural locales that cannot provide the regular flow of electricity that they require.

· The Stop TB Strategy, which is strongly rooted in The Union’s original model of directly observed treatment and the short-course treatment regimen (familiarly referred to as DOTS), has been used to successfully treat more than 56 million people over some two decades, but finding, training, and retaining health workers to do the necessary treatment observation and record keeping remains an immense challenge.

· Shortages of essential medicines are frequent – not only in developing countries, but also in such Western stalwarts as the US and the UK.

· Millions of new, infectious tuberculosis cases go unreported or misreported, often because health workers are overburdened and have no clear managerial direction.

These shortcomings sound a cautionary note to everyone hopefully awaiting “cures” to “eliminate” such champion killers as cancer, AIDS, and heart disease, as well as tuberculosis: discovering the right medicines and strategies won’t alone be the game-ender. Public health needs to get better at using the technologies, strategies, and processes that already exist. This is especially so in low-income countries, with their weaker physical and human infrastructures, where the focus must be on deploying tools that work everywhere.

In tuberculosis, the stakes are high. WHO last week reported that tuberculosis continues to be a major global health problem: in 2012 about 8.6 million people are estimated to have developed it, and 1.3 million people died from it. Disturbingly, 2.9 million of the estimated cases were missed – that is, either undiagnosed or unreported.

As the world’s leaders in the fight against tuberculosis gather in Paris this week for the 44th Union World Conference on Lung Health, much attention will understandably focus on research into new tools. These are, of course, welcome and exciting developments.

But we must work equally hard at developing approaches that will work everywhere the disease claims lives, and at using what we already have more efficiently and with greater impact.

What can we – health professionals, donors, governments and non-governmental organisations (NGOs) – do? First, we need to fill an operational know-how gap. Many public health programmes are directed by talented and dedicated medical professionals who have never received training in planning, budgeting, logistics, operations, human resource management, and communications – all of which are integral to successful public health-care delivery. Second, adequate supply and delivery of existing medicines and other consumables has to become a universal reality, not a target reached inconsistently. Third, the oversight of directly observed treatment needs to be improved in many countries through more attention to recruitment and training, and to developing location-appropriate methods of administering it.

More support is needed for tools that can work in all countries. I often hear reports that such basics as microscopes are malfunctioning or in short supply.

Additional funding is needed, but not an insurmountable amount. The current gap between existing funding levels and the cost to implement WHO’s 10-year Global Plan To Stop TB is $21 billion.

Finally, we need a strengthened spirit of collaboration, globally and locally. Fighting a stubborn disease such as tuberculosis requires a concerted effort by governments, donors, NGOs, and the private medical sector. Collaboration is difficult even when all parties are in accord, but it is simply another management skill that can be learned.

The Union is not alone in identifying these concerns. WHO’s Stop TB Strategy in 2006 identified strengthening health systems as a critical step toward eradicating the disease. Expanded operational research – “the science of doing better” – was also identified as a priority to find local solutions to local problems. And, in the journal Respirology earlier this year, a group of tuberculosis experts said, “Introducing new tools into a deficient system will be unlikely to achieve the improvements we seek… efficiently applying what is available will be the key to achieving success.”

For many decades, rumours of tuberculosis’s demise have been greatly exaggerated in the wake of dramatic research breakthroughs. Great progress has been made, but the disease has outlived every expert who ever made such a prediction. The lesson is clear: this is a war that can and must be won on the ground and in the field, as much as in the laboratory.

Comments

A lot of health worker are definitely talented and dedicated.
It is not all provision or implementing the program.
Implementers from the peripheral unit lack of integrated knowledge of the system on planning, budgeting, logistics, operation, human resource, & communication.
Mostly knowledge & technical knowhow are only coming from managers of the program.

Really a great snapshot on all the operational issues which are relevant in tuberculosis program. I personally think , yes we have scarcity of resources, technical capabilities and off course money, but still we have enough to achieve a sustainable position in terms of indicator. the only problem is with program management: at the policy framing and planning level we have the people only skilled with clinically they do also need to be skilled in program management for better development of program and its various aspects.
And at the ground level we have only loophole with the motivation and capacity with the field workers. they are not well trained with the objective or process with the program, they are just working with a slack way of doing their work and we have various evidence that without determination and motivation we have not achieved any goal so far; Pulse polio program is it self an example to learn.
Also for generating evidence we should work on the success determinants of tuberculosis program in any area and also need to replicate and learn.

Thank you for an in-depth review about Tuberculosis. Really, this illness has caused millions of deaths all around the world. We just have to provide health teachings for the oppressed and the depressed people. Teaching is learning.

Thanks for brliantly reviewing our missing opportunities.It seems we are more inclined these days at focusing on the tip of the iceburg(MDR TB management)while the base of the pyramid(suceptable TB) is bieng enormously fueled by ever weekening Health Systems in resource limited settings.

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